Provider Demographics
NPI:1316515307
Name:WILD, ALEXANDRA GRIFFIN (DDS)
Entity type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:GRIFFIN
Last Name:WILD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ALEXANDRA
Other - Middle Name:GRIFFIN
Other - Last Name:SCHUTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1292 ASPEN WAY
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55118-1750
Mailing Address - Country:US
Mailing Address - Phone:651-815-5678
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY AVE RM 202
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8905
Practice Address - Country:US
Practice Address - Phone:843-792-7365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14619122300000X
390200000X
SCDGD.105741223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program